It is as though someone has drilled peep holes into the walls of emergency rooms, operating rooms and doctors' offices. I can't look away.

Wednesday, April 04, 2007

Heartbroken

Sadly, every word in this post is true.

A while back, there was a little controversy going on in the med-blogosphere and I found it interesting that some bloggers used their blogroll like a weapon:

"I cannot believe you feel this way. I have banished you from my blogroll."

"You are brilliant. I have added you to my Links and put a star by your name."

Addicted to Medblogs ("ATM") has been de-linked twice. I couldn't give a rat's ass about the first de-linking. I still think that blogger is kind of nutty. The second de-linking stung, but I understand why he did it.

But I was heartbroken to learn today that ATM has been removed from the KevinMd.feeds. While I never felt like I deserved it, I was truly honored that ATM was included on the KevinMd.feeds page. I don't know why ATM was removed. Hopefully it was removed because it was unpopular, and not because Dr. Kevin thought it sucked.

So now, drawing on what I have learned from the medblogs, I realize that today I have gone through the five stages of grief:

1. Denial--this can't be happening to me. Surely it must be a technical problem and ATM will be back up tomorrow. Maybe I should e-mail Dr. Kevin.

2. Anger--feelings of wanting to fight back or get even. I am going to de-link KevinMD.feeds. No, I can't do that. I love his blog and the feeds; plus I like the convenience of the link.

3. Bargaining--attempting to make deals to stop or change the loss. Please Dr. Kevin, I will post more frequently.I will finish my research and write an interesting, thought-provoking post on EMTALA [instead of going with my original plan, which was to just write a post asking someone to explain why ER physicians say that they do not get paid for treating uninsured patients. I understand the on-call physician situation, but not ER docs. Not too dumb a question, is it?]

4. Depression--feelings of hopelessness, bitterness and self-pity. Well, yes, but not enough to warrant a visit to ShrinkRap for anything other than entertainment.

5. Acceptance--accepting the loss and finding that good can come out of the pain. I am going to work on my writing skills and improve the quality of posts on ATM. It will be the best damn blog ever written (umm, is delusional part of the grieving process?).

Everyone knows what mends a broken heart. I have to go now. There is a giant bowl of chocolate fudge ice cream in the kitchen with my name on it.

I've never been linked so at least you had the "honor" of being a feed.

I had a med student who delinked me as well and it kind of hurt. I wasn't sure why they did it, but I knew that I hadn't been too excited about keeping them on my links page either - so in the end I delinked. Don't take it personally; afterall, Kevin doesn't even know you.

Awww, MA! I was so happy to see you'd finally returned to blogging, then you go and break my heart with this sad post.

Did you email Dr Kevin about it and find out just why? It might have been a simple oversight on his part. Link love is the currency of the blogosphere...the more links you have, the more readers too. Delinking isn't very productive.

But take heart, you're still everyone's favourite non-medical medblogger. And you get new link love everyday! Kevin MD isn't the world, you know. We still love you :)

If I had to guess, I'd say it was simply a posting frequency thing; purely quantity and nothing much to do with quality.

Besides: get a life! Not to be harsh, but what's the big deal about a blogroll?

And by the way, here's how that other thing really goes: "Gd grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to hide the bodies of all the mofo's I've been forced to kill because they pissed me off." (Great new term, "mofo"; thanks.)

Well, I don't know if I've ever been "delinked." I don't think so. Try not to take it too personally. People get so wrapped up on blogging and why they do it and readership and all of that.

You should be blogging for YOU and because you enjoy it and because it's fun. Yes, it's nice to be linked to others' blogs and it's flattering. I find it so because I STILL can't believe that anyone wants to read my blather but...yes, I can understand how you feel. I just don't want your blogging world to come crashing down because of it.

I "delinked" a few blogs when I migrated to WordPress. One, because it had stayed inactive since I started blogging so I don't even know what happened to the person, a couple of others just because I began to question whether or not they were really appropriate for me as a reader and whether I found them all that interesting. the people never acknowledged me when I commented anyway. It was bizarre, one barely had any activity...etc...

I'm not sure as to why other people "delink." Or even "link?" I suppose everyone has their own philosophy behind it.

If you are really concerned about it, I would as AM suggested, email KevinMD and politely inquire. It couldn't hurt. Again, maybe it was just an oversight. Or if not, whatever the reason is, at least it might quell your anxiety over it all. If you are really upset about it and stewing, you need to alleviate those feelings.

And get back to being the great blogger that you are! Don't let this kind of thing get you down. It's bullshit. Well, okay, your feelings aren't bullshit but there's so much crap already going on in the blogosphere, I just hate seeing more of it when it's someone I know being affected.

BTW, I love your blog---precisely because of your honesty, whether it would ever conflict with any of my beliefs or not. In fact, I like intelligent debate. I don't take it personal if somebody disagrees with me and I would hope that they wouldn't write me off as an idiot simply because I don't agree with them.

I've been in some pretty hot "debates" (er...bloodbaths...) with some of the other blog owners or blog commenters over issues such as universal health (boy, don't go into that argument without body armour...), the ridiculing of ER patients, and other issues that are frequently discussed on medical blogs.

Some blog owners or blog commenters have torn me a new one, and I may or may not have deserved it--but I don't have hard feelings about it because they, too, might have either more wisdom than me or simply a differing opinion.

(Oops--I have done what we here in Podunk call "harped" too long...)

Anyhoo, don't worry about it. I think that people who differ in opinions on the blogosphere should simply "shake hands" over what Texans call a "fair fight"---and not do things like de-link or whatever.

Well, it's a whole new concept, delinking. I was unaware of it as an issue; for all I know I've been delinked, but I never knew when, why, or by whom. I have no idea if I'm on anyone's "feed," and am unsure what exactly that is. I must say I attend more to traffic and number of comments, and when I get very few comments I'm left to wonder if it was a lousy post. I guess I'm happy the link/delink thing isn't much on my horizon. As I guess we all learn, blogging for blogging sake is only the way it is at the beginning. All this other BS threatens to take us over.

As to ATM, I hope you'll just keep posting and ignore the other stuff, because I like coming here and finding stuff.

Hey, we ShrinkRappers have never suggested that our blog is a treatment for depression. We have not submitted our NDA to the FDA, and surely we have a disclaimer against any intended suitability or purpose. (Sorry, we get nervous being linked on attorneys' blogs.)

Anyway, I just found your blog, and like it a lot. And I don't really get what you are saying about EMTALA and ER docs getting paid (we don't get paid for seeing uninsured ED pts).

BTW, we use Blogrolling.com to handle our blogroll. It has features that would limit the number of links shown, weeding out stale blogs without recent posts. Not sure if that is the issue, but I agree with the rest... don't sweat delinking. The only ones I recall delinking have been a few that had no new posts for 6 months and one which turned out to be an ad for a book.

To everyone -- thanks for your comments. I was going to answer everyone individually, but my ass is getting pounded at work today. I need to get back to work or my next post will be talking about how hard it is for an unemployed lawyer to find a new job.

"I will finish my research and write an interesting, thought-provoking post on EMTALA [instead of going with my original plan, which was to just write a post asking someone to explain why ER physicians say that they do not get paid for treating uninsured patients."

Simple question. Simple answer. Most uninsured patients do not pay their bill. "Self pay" almost always equals "no pay". Where I work this is 20-25% of all patients, (about 10% being illegal aliens). Other places it will be higher or lower. It is not any different than an "eat and run" at Denny's or "gas and go" at the corner gas station.

To make this practice even more inviting under EMTALA all "must be served" but the mandate is unfunded. Technically it is not even legal to ask for insurance status or inquire about any type of payment until a person is deemed "stabilized".

Most ER docs, like my self, belong to a group that is self employed. We provide a service and then hope to collect and get paid fo services that were already provided. Usually the hospital is completely separate and does not provide any salary, or guanrantee of one. Some groups (e.g. Kaiser, some hospitals, Academic centers, VA) will pay ER docs a salary as an employee. The trickle down effect of "no pay" patients however is still going to reflect in the salary provided by the hospital.

Of course even though this crowd does not pay their bill, they still like to sue!!

Jerry, thank you. The picture is a lot clearer now. Although it does raise a whole new set of issues in my mind. This is turning out to be an interesting topic and I am going to try to do a little more reading up on it. It's a hellava lot more interesting than what I am researching at work right now.

Anonymous--Kevin never de-linked me, he took me off his "feeds" page. Although if he ever reads this post, he might also de-link me. LOL. Thanks for stopping by and commenting.

I tagged you for a meme - 5 memories :)Some people do them - some don't. Your busy - but I bet you've got some good ones to share. :)

I did mine as 5 early memories. Of course I may delete them before you see them - that whole wrestling thing - leave it - don't leave it - leave it. I'm going to bed but when I wake up in the morning I might lunge toward the computer to delete. I prefer to keep things light.

Ha! I did go to bed, but withing a half hour I flew out of bed to take the 2nd part of #4 out and some other info out of #5. #4 was funny but then unfortunately I had a older pervert next door neighbor that became a 2nd part of that story that I decided to remove because, well, because YUK! :(

"...Why ER physicians say that they do not get paid for treating uninsured patients. I understand the on-call physician situation, but not ER docs. Not too dumb a question, is it?"

As a veteran in Emergency Medicine, please allow me to "learn" you on the intricacies regarding the sources of an ER doc's pay. It all depends on the hospital setting where your practice is at that will ultimately determine which payment model you fall under.

1. Fee-for-service. This model is rare but does exist. Good luck in finding it. You see patients, you bill patients and insurance companies, you collect whatever patients/insurance companies pay you. You share the billing service cost with your partners. This model is only ideal in a hospital setting where the majority of clientelles are well-insured because if patients aren't paying you, you're screwed. EMTALA is still after all an unfunded mandate.

2. Equal partnership, nonsubsidized. Everyone in the group sees patients and bills patients/insurance companies. The collected pot is equally shared by all, some more equal than others based on seniority, of course. The loss of unpaid bills is equally shared by all. Such is an oversimplication of the model, not accounting for productivity bonus measured by patients seen/hr, number of shifts worked, etc...Thus, if patients don't pay you, you get less $$$, but at least the miserable butt f'in is equally felt by all members of the group.

3. Equal partnership, subsidized. This is perhaps the prevailing model for the majority of ER docs in private groups, and certainly is the model of many busy county hospitals. High uninsured patient demographics translate to low reimbursement rates. Fact. In order to keep the doors of these busy places open, hospitals must kick in a subsidy to the contracted physician groups through federal, state, county and city fundings, or any other means like private donations, bond issues, etc... Aah, but the funds are not unlimitted. Aye, thar's the rub.

Group physicians send out bills to all patients and insurance companies, only a paltry percentage pay. To offset the difference, hospitals must kick in a subsidy, but will only give enough to meet the minimum line and support solvency of the group, of course. Group physicians whine, "Damn, our census has just tripled over the past few years, we need more money to hire more docs in order to handle the volume!" Hospital administrators answer, "I wish I can pull money out of my ass to give you guys more so you can hire more docs, but with piss poor reimbursement rates and limitted fundings that are cut every year, you sorry saps are on your own!" As a result, the lines and waiting time at the county hospitals get longer and longer. And as a doctor at one of these places, you must work harder, see more patients, put yourself at higher liability, but not getting paid a penny more. You're just getting the juice squeezed out of you until you burn out. Then there's also the hospital administrators mind games you have to deal with as well, because they will pull any below the belt ploys to withold your deserved money. From tying patient satisfaction survey scores to utilization reviews, those hospital administrative sons of bitches will do anything to give you less and less and pocket more for themselves. Bastards!

4. Fixed pay. These are your independent contractors, moonlighters, and docs who are either salaried employees of a hospital or of a private corporate group. These docs are paid a fixed salary, usually hourly, regardless of how many patients they see, and thus are not constrained by productivity. But still, with any business model, if the owners cannot collect enough the trickle down effect won't work for long...well, you know what I'm getting at.

I hope this oversimplication makes things a little clearer.

(BTW, I've just been too lazy to add any links to my blog and have taken a break from blogging for a while. I'll get around to it one of these days and promise to add yours to mine.)

Charity Doc: Informative and entertaining--this is why you are one of my favorite writers. Thank you. This is exactly what I was looking for and it is way too good to leave hidden in my comment section. I understand you needing a break, but I’m selfish so I’ll just say it: Hurry back because I will miss you.

Charity Doc - I remember back in the early 90's our hospital was operating in the red. The head Doc of that ER group was saying that the hospital wasn't giving the Docs their money because they didn't have it to give. So, when he did get the checks he paid the docs under him first.

The hospital soon went on board with a larger hospital system, which was a good thing because the merger saved our hospital's doors from closing.

Seems that everyone in the health care system is having to fight to keep their money or to get their money.